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A 25 yr old female with fever since 3 days

 Name: G.Pravallika  

Roll no 41


This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients' problems through a series of inputs from an available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence based input.

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 


Date of admission: 28/11/23


A 25 yr old female with the chief complaints of 

℅ fever since 3 days

℅ passage of loose stools since morning-3 episodes 

℅ vomitings since morning

History of presenting illness:

Pt was apparently asymptomatic 3 days ago then she developed fever insidious in onset, gradually progressive high grade. No aggravating or relieving factors. Then she developed a passage of loose stools, watery since 1 day and vomitings since 1 day non projective , non-blood tinged , food as content , non bilious. 

H/O body pains, petechiae, subconjunctival haemorrhage.

No H/O of cough, palpitations, pedal edema, increase or decrease of urine output, abdominal pain, melena, retro orbital pain.

PAST HISTORY :

no h/o HTN,DM, epilepsy thyroid disorders ,asthma.


TREATMENT HISTORY

no h/o significant treatment history.


PERSONAL HISTORY 

Married

Diet is mixed

Appetite is lost since 2 days

Bowel movements- Irregular, loose stools since morning

Bladder movements- Regular

Sleep is adequate

No h/o allergies



FAMILY HISTORY

not significant


MENSTRUAL HISTORY:

Menstrual cycles are regular , 28 days cycle , 5 days menstruation.


GENERAL EXAMINATION:

pt is conscious coherent and cooperative

No pallor

No icterus

No pedal edema

No cyanosis

No koilonychia.

No lymphadenopathy



VITALS:

Temperature:99 degrees F

Pulse rate: 75 b/min

Respiratory rate: 21cpm

Bp: 100/80 mmHg

SpO2- 98 %

GRBS- 203mg%




SYSTEMIC EXAMINATION:


CVS

S1S2 heard, no murmurs


Respiratory system 

Trachea central

Normal vesicular breath sounds


 Per Abdomen 

Shape of the abdomen scaphoid

No tenderness

No organomegaly

Hernial orifices- normal

CNS 

Conscious and alert

no focal neurological deficits



Provisional diagnosis:


Dengue



INVESTIGATIONS:

CBP, LF, RFT, USG Abdomen, Serology (NS 1 antigen), Serum electrolytes, ECG, APTT, INR, HbA1c, FBS


CBP

Hb - 15.6 g/dl

Platelets- 56,000 

TLC- 2130 

MCV - 82

Blood Group - AB+ve


Serology


NS1 antigen - Positive
IgM - Negative
IgG - Negative

Serum Urea - 26 mg/dl

Creatinine - 0.7 mg/dl

LFT

SGOT - 96
SGPT - 71
ALP - 191
Total Protein - 8.1 mg/dl
Albumin - 4.4 mg/dl
A/G-1.21

Serum Electrolytes

Na+ - 135 
K+ - 5.3
Cl- - 98

PT- 17
INR - 1.2
APTT - 39

ECG


 USG Abdomen

TREATMENT


28/11/23

  1. IV fluids NS @75 ml/hr

  2. Tab. Doxycycline 100mg PO/BD

  3. Inj. Optineuron 1 amp in 100 ml NS IV OD

  4. Temperature 4th hourly

  5. BP monitoring 2nd hourly

  6. Inj. Zofer 4mg IV BD

  7. Inj. Pan 40 mg OD

  8. 1 ORS sachet in 1 l water

  9. 200 ml ORS after each episode of loose stools


29/11/23

  1. IV fluids NS @200 ml/hr

  2. Tab. Doxycycline 100mg PO/BD

  3. Inj. Optineuron 1 amp in 100 ml NS IV OD

  4. Temperature 4th hourly

  5. BP monitoring 2nd hourly

  6. Inj. Zofer 4mg IV BD

  7. Inj. Pan 40 mg OD

  8. 1 ORS sachet in 1 l water

  9. Inj. PCM 1 gm IV if temp > 101F




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